Get 844 521 6942

Filling out the 844 521 6942 form online is an essential process for obtaining preauthorization for services under Healthy Blue Medicaid Managed Care. This guide will provide you with clear and systematic instructions on how to accurately complete the form to prevent any delays in your request.

Follow the steps to complete the form effectively.

1. Press the 'Get Form' button to access the form and open it in your browser.
2. Enter today's date in the designated section of the form.
3. Fill in the provider return fax number to receive feedback on your submission.
4. Complete the member information section with the member’s first name, last name, Healthy Blue member ID, address, city, state, ZIP code, date of birth, and contact phone number.
5. Provide additional member information as required.
6. State whether the referring provider is participating or nonparticipating, and fill in their full name, NPI, provider ID, TIN, office contact name, office phone, office fax, address, city, state, ZIP code, and specialty.
7. Repeat the previous step for the servicing provider, ensuring to indicate if they are participating or nonparticipating.
8. Next, fill in the servicing facility's details in the same manner, specifying NPI, provider ID, TIN, facility contact name, facility phone, facility fax, address, city, state, ZIP code, and specialty.
9. In the requested service section, check all applicable types of services and enter the date or date range of service, ICD-10 code(s), and CPT code(s) along with requested units.
10. Select the place of service from the provided options.
11. Provide any additional information that may support your request.
12. If this is a request for an extension or modification of an existing authorization, include the authorization number.
13. Once all fields are completed, review your entries for accuracy. You can then save changes, download, print, or share the form as necessary.

Complete your document online and ensure a smooth process by following the steps outlined above.